a blog of books every doctor should read

How Doctors Think

BOOK CONTENTS

Written by a leading physician, this book explores the vulnerabilities of doctors’ thinking; it is ‘…a book about what goes on in a doctor’s mind as he or she treats a patient’ (page 3). It is one of the few books to bring the limitations of doctors’ decision-making to the lay public. The author showed how ‘cognitive traps’ impair doctors’ thinking and he acknowledges that many clinicians are not explicitly taught how to think (page 4). Using fitting examples, he referred to many heuristics and biases that may impair doctors’ judgments. For example, he demonstrated the representativeness heuristic in the context of chest pain which was downplayed because the healthy-looking patient did not fit the typical picture of someone who would develop a heart attack (page 44).

He discussed the availability heuristic with the story of a patient with aspirin toxicity who was misdiagnosed as viral pneumonia. Other cognitive errors he enlivened with excellent narratives include confirmation bias, anchoring, affective error, diagnostic momentum, and search satisficing. He acquaints readers with Amos Tversky and Daniel Kahneman, psychologists who have carried out seminal work in this area (page 64). He also cited patient safety leaders with expertise in human factors such as Pat Crosskerry and Donald Schon.

A theme the author strongly expounds is the impact of mood and feelings on doctors’ clinical judgment, and he expressed his concern that most doctors do not recognise this (page 40). He says ‘cognition and emotion are inseparable’ and ‘the doctor’s negative feelings cloud his thinking’ (page 39). He uses the Yerkes-Dodson curve to show the influence of inner feelings on decision making (page 36). He also underlined the effects of time pressure, financial interests, and administrative targets on a physician’s decision-making. He suggested that the conformity and orthodoxy taught in medical school also negatively influence doctors’ thinking (page 153).

The author’s discussion of ‘disregard of uncertainty’ is worth mentioning. Quoting another physician, Jay Katz, he explained why uncertainty exists in medicine and why doctors need to ‘keep these uncertainties in mind and acknowledge them to patients’ (page 152). The author urges doctors to acknowledge uncertainty saying ‘taking uncertainty into account can enhance a physician’s effectiveness because it demonstrates his honesty, his willingness to be more engaged with his patients, his commitment to the reality of his situation…’ (page 155).

The author concludes with several helpful tips to patients. Key is his suggestion that patients should help doctors think by asking pertinent questions such as ‘What else could it be?’, ‘Is there anything that doesn’t fit?’, and ‘Is it possible I have more than one problem?’ (page 263). He advises doctors to avoid haste and cutting corners in their decision-making as these are ‘the quickest routes to cognitive errors’ (page 268).

OPINION

This well-researched book graphically illustrates the factors that influence how doctors think. It uses excellent anecdotes to good effect and the storytelling is masterful. The author simplified the important biases that influence doctors’ judgments and made this relevant for the lay reader. I thought the author did not stress the point that many of the flawed thinking processes he discusses are normal human traits. This is important because the remedy has as much to do with vigilance as it does with creating fail-safe systems.

OVERALL ASSESSMENT

This book brings an important issue to light and does so skilfully. His target audience is the lay public but it is relevant to doctors. The lessons are useful for healthcare and I highly recommend it.